Provider Demographics
NPI:1063282689
Name:BRIDGE 2 SUCCESS GROUP HOME, INC
Entity type:Organization
Organization Name:BRIDGE 2 SUCCESS GROUP HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LEKEYSHA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:AYENUMELO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-307-3845
Mailing Address - Street 1:902 KROLL LN
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27260-5851
Mailing Address - Country:US
Mailing Address - Phone:336-307-3845
Mailing Address - Fax:336-307-4376
Practice Address - Street 1:902 KROLL LN
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27260-5851
Practice Address - Country:US
Practice Address - Phone:336-307-3845
Practice Address - Fax:336-307-4376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness